Recreational MDMA testing - a European perspective

By Oli Stevens

As the United States experiences an overwhelming opioid crisis; as the world’s press is flooded with extra-judicial killings targeting drug “offenders” in the Philippines; as young Australians overdose on novel psychoactive substances and teenagers in the UK on ecstasy, there can be only one certainty: drugs are here to stay. Despite some countries reaffirming farcical commitments to a drug-free world, with over $100bn spent annually on the War on Drugs, and 20% of the world’s prison population incarcerated on drug offences, drugs have never been cheaper or purer.

Providing regulated drug markets remain a pipe-dream (excluding cannabis) and transnational drug supply the remit of the criminal underworld; profit will always reign supreme. To maximise profit, drugs are frequently diluted with adulterants to make two kilos into three, or simply mimicked by cheaper, possibly harmful, replacements. Whilst some adulterants are benign (caffeine in cocaine), many are not (PMA/PMMA in ecstasy, fentanyl in heroin).  Consequently, in addition to the known potential harms intrinsic to any given drug, users expose themselves to an array of truly unknown harms.

Enter harm reduction – the concession that as drugs have been indelibly woven into the fabric of society, there should exist means to reduce their adverse health, social and economic consequences, independent of reducing their consumption. Drug testing is but one facet of harm reduction which enables users to shine light on unknown harms and then make an informed, or at least less arbitrary, decision on whether to consume or discard. Drug testing can broadly be divided into three categories: test kits; on-site testing at clubs and music festivals; and ‘send-away’ testing to a professional laboratory. To be succinct, this article will focus on ecstasy pills (MDMA) in Europe.

Test kits are vials of chemical reagent which change colour in the presence of a drug. The testing method is simple enough - a drop of reagent is added to a small sample of drug (a pill scraping or a few milligrams of powder). Then, much like a school chemistry experiment, a colour change occurs. So that’s it, problem solved? Not exactly. For any given reagent, no single drug produces a unique colour. Rather, the reagent reacts with a specific structural motif within the molecule. These motifs are often shared between drugs, leading to a wide range of colours and reactivity and considerable overlap (in practice, the colours are even harder to discriminate). To distinguish MDMA confidently from its analogues and imitators requires three tests in sequence, each eliminating uncertainty from the last, yet can still fail to identify low-dose, highly toxic ingredients. Attempting to discriminate between practically identical colours, potentially the difference between dancing until the early hours and intensive care, cannot, and should not, be done in the corner of a nightclub toilet.

I contacted Dr John Ramsey, director of TICTAC, for his thoughts, “Colour tests may give a nice colour, but that's it: no information on quantity and unreliable information on composition … They are only indicative at best”. Dr Mireia Ventura, drug checking coordinator at Energy Control, agrees, “With PMA/PMMA and the emergence of new psychoactive substances [‘legal highs’] as adulterants, colourimetric tests are not enough and a positive result could generate a false security.” The total lack of information on quantity is of particular concern: across Europe, ecstasy pills are increasing in both purity and dose. At present, high-dose pills, rather than adulteration, seem to cause the majority of hospitalisations.

Drug markets, however, are highly region specific. Most the world’s MDMA is made in the Netherlands and Belgium, while supply outside Europe is much scarcer. Accordingly, in the USA, as Mitchell Gomez of DanceSafeexplained to me, the issue is misrepresentation, rather than adulteration (i.e. things sold as MDMA rather than added to) so that colourimetric tests remain reliable. In 15 years of laboratory testing, only three samples containing PMA/PMMA have been documented in the USA.

As colourimetric tests are of limited use to the European user, more sophisticated testing is required to provide robust, reliable results. Whereas colourimetric tests are freely and legally available online, the creation of funded, structured, and visible testing programmes requires delicate legislative footwork. Without the assurance that testees will not be arrested entering testing facilities nor indeed testers on possession charges, formalised testing schemes cannot proceed.

Several European countries have had forward-looking, public health-centred drug policies for several years, permitting the formation of ‘send-away’ drug testing programmes – now both well-established and popular. I contacted Drug Information and Monitoring Service (DIMS) (The Netherlands, established 1992), Energy Control (Spain, established 1997) and SaferParty (Switzerland, established 2001) to gain a better understanding of the environment surrounding testing. I rapidly realised that I was asking somewhat primitive questions from the perspective of a British citizen, from a country which has chosen to cling to backward, tired and ineffectual rhetoric.

Probing issues of relationships with the police, transport of drugs by post, and immunity of testees from prosecution, the answers were clear and simple. Dr Tibor Brunt explained that DIMS “have a special agreement with the public prosecution office that they do not interfere with [our] work”; the agreement extends to registered and signed parcels to permit the movement of illicit drugs by post. For Energy Control, the situation is simpler still: the quantities received by post are so small that they are considered for research purposes and need no further legislative changes. Christian Kobel of SaferParty says that though legislation surrounding testing “is not completely clear”, harm reduction is one of the four pillars of the Swiss Narcotics Act and Swiss states have an obligation to provide “harm reduction and survival support measures”. SaferParty’s relationship with the police is crystal clear: they meet to discuss best practice, provide statistics on tested drugs, and discuss emerging drug trends such as the darkweb. In 15 years, there has been no police intervention on any drug-checking site, whether mobile or static.

In countries where testing services operate without sanction from regional or centralised Government, on-site services (i.e. at music festivals or clubs) are easier to set up, ‘only’ requiring support (or at least tolerance) from local law enforcement. These services, whilst lacking a full laboratory, use portable analysis devices, often in combination with colourimetric testing, to give highly accurate results. Prof. Fiona Measham, co-director of The Loop, the charity behind the first on-site drug testing in the UK, explained to me that “testing operates with the full support of local police and [we] work very closely together from the start. The Police want the testing, they don’t just tolerate it”. 

Though national governments are often sluggish beasts, beholden to voters and wary of scandal, local law enforcement is able to work with forward-looking initiatives, bringing effective policy to the front-line much more rapidly than top-down policy. Measham notes that the UK Government is not openly opposed to testing nor to local police forces electing to ‘deprioritise’ cannabis possession, rather they are “watching and waiting for the evaluation”.

Whereas The Loop operates in close cooperation with the law, DanceSafe benefits from the police turning a blind eye: “law enforcement has very little interest in low level possession arrests, and in all the years we have been testing we've never had a volunteer or a testee arrested. In most [US] states needles are 'paraphernalia', and setting up outside a needle exchange would be an easy way to make arrests, but the police understand this is counterproductive to their ultimate goals.” Some comfort may be found in a remark from Prof. Michel Kazatchkine of the Global Commission on Drug Policy: “decriminalisation and regulation must start at the local, city, subregional level”. Harm reduction, now central to many national drug policies, started this way - perhaps so too will drug testing.

The numbers speak for themselves – no one at SaferParty can recall an ecstasy-related death, despite Zurich’s love for raves and techno; at The Loop’s first UK music festival, 25% of people discarded their tested drugs; and DanceSafe’s anecdotal evidence suggests that discard rates of misrepresented MDMA approach 100%. The benefit reaped from drug testing services goes considerably above and beyond offering information to an individual user about an individual drug sample. In Europe, most of the drugs tested are ecstasy pills which can easily be distinguished due to their colour, shape and patterning. Upon detection of toxic contaminants or a particularly high dose, early warning systems can be utilised to disseminate information rapidly and effectively.

Shortly before Christmas 2014, DIMS detected lethal quantities of PMA in a pill and released a ‘red alert’. The alert was circulated on national television, on screens in clubs and through the dedicated mobile app. No one died. Not so in the UK. The same pills killed 4 people over the festive period. The same pills resurfaced in October 2016 and, as these were recognised by users, there were no further casualties. Though there exists an EU-wide Early Warning System which monitors emergence of new psychoactive substances and provides risk assessments for them, it cannot, neither is it intended to, respond to the highly dynamic drug market on a local level. As part of a balanced, public-health driven drug policy, countries should offer official, local early warning systems to monitor variability between batches of existing drugs whose composition can fluctuate on a week-by-week or town-by-town basis. Failure to provide these systems has been, and will continue to be, a fatal decision.

Sites also act as a point-of-contact between users and drug services, offering consultations and counselling to people with problematic drug use who are often unwilling to engage with traditional health, social, and harm reduction services. In exchange for drug analysis, users must fill in an anonymous questionnaire. In addition to valuable epidemiological data which can be fed back into and improve national Drug Action Plans, the questionnaires reveal how, compared to other official sources of drug information, testing sites are perceived as more trustworthy, less judgemental and more accessible.

As venues around the world threaten lifetime bans and while music festivals increase security and sniffer dog presence, attendees wishing to take drugs face a dilemma: buy unknown drugs inside a venue or consume large and irresponsible quantities in the queue, further risking their health; or bring validated drugs into the venue, risking conflict with the law. Dr Ventura’s ideal future combines both centralised and on-site testing: “With centralised testing, you're offering a real prevention service, providing the results before consumption and you're also promoting planning to drug users. On the other hand, testing at clubs could remove toxic adulterants from the venue if you properly advertise the results. When we offer front-of-house drug testing we see how warnings detected at the beginning of a festival disappear by the end.”

The illicit drug market is free from any official quality control, and users are at the mercy of suppliers. This creates a profound case of asymmetric information between suppliers and users, permitting drug supply of any composition to clueless, hapless buyers. Drug testing offers a form of pharmacovigilance, providing a method by which users can exert some control over an entirely unregulated market. The Trans European Drug Information project note that “manufacturers will be less inclined to trade in dangerous substances or adulterants if they know that there is a way for consumers to test their product … if dangerous substances can be identified via a warning campaign, traders are more inclined to rapidly withdraw their products from the market”. Drug testing, therefore, acts not only as a personal harm reduction initiative but has the capacity to shape the very composition of the market itself.

Regrettably, none of this is news. Jaap de Vlieger, drugs specialist with the Rotterdam police, speaking about contaminated pills over 20 years ago in 1995: "The people who make this stuff aren't going to dump a load of valuable pills into the canal. They're going to sell them in countries like Britain where the chances of them being traced is small, because people are too scared to go to the authorities."

If governments refuse to regulate drug markets, perhaps testing can. 

THCV - an abject cop-out from the ACMD, another research opportunity for the UK lost

By David Nutt

The cannabis plant produces over 100 compounds with therapeutic potential. Most of these have never been properly studied because of the complications of researching any cannabis plant extract that might contain d9THC, the “stoning” element of the “herb”. D9THC and many related compounds are controlled under the 1971 Misuse of Drugs Act [MDAct1971]. Here they are placed in Class B [drugs of moderate harm] alongside amphetamines, which means that supply can result in up to 14 years in prison.  In the same Act, they are also controlled as Schedule 1 drugs, alongside crack cocaine.  Drugs are put in Schedule 1 when the Home Office, guided by the ACMD, determine that they have no medicinal value. The fact that cannabis is in Schedule 1 when it was, until 1971, a licensed medicine and is now restored to that status in 18 countries and most American states is scientifically bewildering. Even more absurd is that a synthetic form of d9THC, dronabinol, is a licensed medicine and is in Schedule 2. 

Schedule 1 status is to drugs what Catch 22 is to military psychology. Drugs can only escape Schedule 1 if they can be demonstrated to have medicinal value yet because they are in Schedule 1 research with them is almost impossible. The Home Office, in a money-making exercise, charges over £3000 for a Schedule 1 licence that takes one to two years to get.  It  requires all those working with these drugs to pass a higher CRB check, even if, like me, they are licensed doctors. I can prescribe heroin but need special clearance to prescribe  cannabis for research in case I am tempted to misuse it!  These absurd regulations are so onerous that only 4 hospitals in the UK have a Schedule 1 licence which is why so little therapeutic research on cannabis takes place in this country. This is especially frustrating as UK scientists were the first to identify many of the chemicals found in the cannabis plant. Now we lag years behind Israel and the Netherlands.

DrugScience has repeatedly tried to get the Home Office to be more logical about this state of affairs, in particular over one cannabis derivative: THCV (also known as cannabivarin).  UK scientists from Reading University were the first to show that this has potent anti-epileptic properties. Other UK researchers have shown THCV to have potential in obesity, anxiety and even possibly as a treatment for schizophrenia.  However this research has been very difficult; for example it took Prof. Phil Cowen in Oxford two years to get permission to use THCV in an anxiety experiment in normal volunteers, let alone patients.  The Schedule 1 status also adds massively to the costs of the drug as all the suppliers and manufactures need to get licenses too.

Because of this difficulty a number of psychopharmacology experts including Prof. Robin Murray from the Institute of Psychiatry asked the ACMD to review the status of THCV since their experience suggested that it was not like d9THC – if anything it was an anti-THC behaving rather as an antagonist. So there would be no abuse potential and so no reason to keep it as Class B.

This week the ACMD reported on its review of plant-based cannabinoids and decided that THCV should stay in Schedule 1 despite the body of data I have already mentioned. Their decision on THCV makes embarrassing reading to anyone hoping for a rational policy that would balance scientific goals with public concerns.

I will summarise their decision for you. They found a study that reported in 1974 which found some d9THC-like psychoactivity from THCV. This study was flawed in many respects and would not be accepted by current scientific journals because there was no placebo condition so blinding was impossible.  Moreover in this study the THCV was given intravenously and in high doses, both of which would be predicted to alter its brain effects. Finally there was no proof of quality control so it may have had some d9THC or other psychoactive cannabinoids in it.  These flaws mean its findings are of little relevance to the current human therapeutic situation where the drug would be given orally.  However the ACMD group decided to cling to this straw of possible d9THC-like psychoactivity rather than accept the newer literature that shows it may be a d9THC antagonist. They recommended keeping it a Schedule 1 drug until more research of therapeutic value has been done, which will now probably never happen [at least in the UK] for the reasons described above. 

This is a hugely disappointing decision because if THCV is a functional cannabis antagonist it could be very useful as an antidote for the psychosis-producing effects of the vast range of synthetic cannabinoids (spice) that are ravaging our prisons and poorer communities. The only other cannabis antagonists that might be useful in this current public health emergency such as rimonabant have long since disappeared when their benefits were dismissed by the FDA. 

What should the ACMD have done?  They should have had the courage to acknowledge the therapeutic potential of THCV and moved it completely out of the MDAct1971 just like cannabidiol (CBD).  This would have allowed researchers much faster and cheaper access and also encouraged many more into this research space. This would not have led to increased recreational use as THCV is a) very expensive and b) only psychoactive when injected intravenously, an action few, if any cannabis users would even consider, let alone do. Even if it turned out that THCV did have some recreational use, this could then be dealt with through the new 2016 Psychoactive Substances Act, which, though intellectually dishonest, does at least have the merit of specifically exempting research from penalties.

An unhappy Christmas for UK research: how the law against synthetic cannabinoids might destroy pharmaceutical discovery in the UK

By David Nutt

On December 14th the government put into effect new controls against a whole range of synthetic cannabinoids.

This was their third round of controls against these new hyper-potent recreational cannabis agonist drugs that have taken over many of our prisons and also are wreaking havoc in the homeless population.  The first two sets of controls on the earlier synthetic cannabinoids were rapidly surmounted by “underground” chemists who found new cannabis analogues to replace the banned ones. In an attempt to prevent this happening again the ACMD recommended to the Home Office that this third set of regulations should cover a more extensive range of substances. To achieve this they recommended banning a range of chemical series that were a part of the current crop of synthetic cannabinoids and which they predicted would necessarily be part of any future synthetic cannabinoid drugs. Any drug meeting these chemical criteria is now controlled as a Class B Schedule 1 drug under the Misuse of Drugs Act 1971.

When DrugSciences's chemistry experts heard of this plan early in 2016 they pointed out to the ACMD that this was a misguided approach. The chemical structures they were proposing to ban were contained in a number of current medicines such as the anti-inflammatory medicine indomethacin and in several of the sartan anti-hypertensive agents. These would therefore become illegal once the new law was enacted. The ACMD didn’t respond to our suggestions but presumably took the criticism on board as, when the regulations were announced, they tried to get around the problem by specifically exempting medicines that would otherwise have become illegal. The list given in the new regulation covers the following medicines - clonitazene, etonitazene, acemetacin, atorvastatin, bazedoxifene, indometacin, losartan, olmesartan, proglumetacin, telmisartan, viminol, zafirlukast.

However this exemption-based approach has a fatal flaw. Most, if not all, of these drugs were derived from chemical series that contain precursors to other drugs that might also be developed as medicines. Because these investigatory and precursor chemicals are not in the public domain they cannot be exempted, so are by default illegal. The new law means they would fall into Schedule 1 and Class B of the MDAct1971, making anyone caught supplying them liable to up to 14 years in prison and simple possession up to 5 years.  These threats to researchers will have a chilling, possibly fatal, impact on pharmaceutical drug discovery research in the UK since complying with the regulations around Schedule 1 Class B drugs adds a vast cost burden to industry and academic researchers.  As DrugScience has pointed out, experience with similar legislation over cathinones and ketamine analogues tells us that research on this type of compound effectively stops dead once whole chemical series are outlawed [1,2,3].

What is remarkable is that the Home Office appears to have ignored not only DrugScience, but also its own regulations on consultation before enacting the new amendment. The body representing the pharmaceutical industry – the ABPI – [the Association of the British Pharmaceutical Industries] was apparently not consulted and is now up in arms about the new law. Neither it appears were the UK universities, some of whom have medical or pharmaceutical chemistry research groups.  One academic research chemist has told me that it is now likely that in almost all organic chemistry practical classes at some point a now-illegal substance will be made!

Moreover this approach is very unlikely to impact the availability of synthetic cannabinoids since they are so potent that they are almost impossible to detect and easily smuggled into prisons [they can easily be hidden absorbed into small tabs of paper]. Worse there is very limited evidence – if any – that the first two synthetic cannabinoid bans led to a reduction in usage or sales. The ACMD may now have created the worst possible outcome, an ineffective new law that could produce severe collateral damage to the UK research community.

What should the Home Office do in addition to retracting the new law?  First they should stop the behaviour that led to the synthetic cannabinoid problem in the first place: the enhanced policing and testing of the public and prisoners for herbal cannabis. Second they should work with a range of experts to develop ways to identify and test the pharmacology of specific synthetic cannabinoids so that specific drugs, and not general chemical classes, are made illegal – this is the approach used by the UN and WHO.  I suspect one reason they don’t want to use this evidence-based approach is because their current Schedule 1 status makes research with these compounds so difficult and costly that few (if any) groups have the resources and resolve to conduct such research. If legislative control is thought politically necessary, then a more rational approach would be to regulate new synthetic cannabinoids under the Psychoactive Substances Act, which at least has the benefit of exempting researchers from possession penalties.

Also they should develop other solutions to the harms done by synthetic cannabinoids particularly by resurrecting antagonists to these drugs that will reverse the toxic actions of these in the same way that naloxone reverses the dangerous effects of heroin. Last year I put a paper explaining this approach to the all-party parliamentary interest group on drugs and drug addiction but it seems there is no government route to support this kind of intervention.  Perhaps the ACMD could take up this challenge and so do something useful for the field?


  1. Nutt DJ, King LA, Nichols DE (2013) Effects of Schedule I drug laws on neuroscience research and treatment innovation. Nat Rev Neurosci. Aug;14(8):577-85. doi: 10.1038/nrn3530. Epub 2013 Jun 12
  2. Nutt DJ (2011) Perverse effects of the precautionary principle: how banning mephedrone has unexpected implications for pharmaceutical discovery Advances in Psychopharmacology 1: 35-36  DOI 10.1177/2045125311406958 
  3. Nutt, D. J., King, L. A., & Nichols, D. E. (2013). New victims of current drug laws. Nat Rev Neurosci. doi:1038/nrn3530-c2 Ref 467

Better late than never? After 82 years the WHO reviews cannabis!

By David Nutt

The WHO is the world’s leading health organisation guiding governments around the world. So we expect their advice to be up to date and evidence-based, particularly on controversial topics. One of the most controversial topics of our time is the international community’s approach to drug policy, particularly that relating to the most popular so-called “illegal” drug – cannabis. Yet the WHO’s advice on the harms and (lack of) benefits of cannabis is based on a decision made 82 years ago, by its predecessor, the League of Nations. Thankfully, there is now hope that this is about to change.

The WHO advises the UN, which states international control of drugs – so the view of the WHO really matters. The reality is that almost every country in the world (197 in total) sign up to follow WHO advice and so its current stance means punitive measures for cannabis – including lifetime in prison in some countries. Cannabis is still scheduled as having the highest level of harm and no medical value, despite reams of evidence to contrary. It is significantly less harmful than alcohol and shows real medical benefit, particularly in the treatment of pain, spasticity, and some forms of epilepsy. Due to these therapeutic effects, over 18 countries and over 200 million US citizens now have access to licensed medicinal cannabis. Consequently, the idea that cannabis isn’t a medicine is considerably less plausible now than when this decision was made in 1934. Worse still, the actual report on which cannabis was scheduled in 1934 can no longer be found so it may be that the decades-long ban on cannabis is based on real errors of fact!

What is equally problematic is that the current legal status of cannabis means that research into its potential benefits – or harms - is really tough because of the regulations that accompany its Schedule 1 status. For example, in the UK medical researchers like me need a special license to hold cannabis for research though as a doctor I can prescribe heroin - a much more dangerous and sought-after drug. The UK government believes that it can’t change this prohibitionist position and still comply with the UN conventions. This is untrue, as The Netherlands has demonstrated for over 30 years, but the easiest way to get a change in the UK policy would be if the WHO led the way.

It is vital that experts take all latest data into account during such a vital review, and to this end DrugScience has produced a detailed up-to-date assessment of cannabis for the public as well as the WHO and UN. This report authored by 4 experts – two from DrugScience - provides the vital background evidence on which a sensible modern re-assessment of cannabis can be made. This should lead to an appreciation that cannabis has medical value in some illnesses, and so encourage research into its potential for others, such as cancer, ADHD and PTSD. A proper review of cannabis could also encourage a more nuanced view of the comparative harms of different forms of cannabis, helping direct users away from the strong d9THC/low cannabidiol variants such as “skunk” that appear significantly different from more traditional herbal or resin forms of cannabis.

Big issues like this need that affect hundreds of millions of people across the globe need to determined based on the best and most current evidence available. Leading organisations such as the WHO and UN need to be able to move quickly to try and avoid the public losing out.

At last there has been some progress! This came from the recent meeting of the WHO Expert Committee on Drug Dependence in the WHO headquarters in Geneva. Here the Expert Committee and the WHO Lead for Medicines, Dr Suzanne Hill, were presented with the report by the DrugScience team. They also heard powerful supporting arguments from two other expert groups (the International Drug Policy Consortium and the International Association for Hospice & Palliative Care) both of whom also made it clear that there was a pressing need for a review of cannabis scheduling.

The DrugScience team argued that the Expert Committee had the right to change its agenda to start a full pre-review of cannabis immediately based on our WHO-standard report. This they declined to do, but it seems our arguments were heeded as an official pre-review has been ordered, to be completed before the next meeting of the Commission on Narcotic Drugs in 2018.

This move by the WHO is encouraging as its perception as being an evidence-based health organisation has become seriously questioned by its failure to consider the evolving facts on cannabis. It is critical that the review they conduct is honest, transparent and fully evidence-based; for surely then it will be impossible for the UN to continue to argue that cannabis should be scheduled as being extremely harmful and lacking medical value!

‘Scotch mist’: the ongoing saga of Alcohol Minimum Unit Pricing

By Eric Carlin

‘Scotch mist’ may be taken to refer to a whisky-based beverage (Scotch whisky, crushed ice and lemon peel). More traditionally, the term refers to the drizzle, neither full-on rain nor proper mist, that frequently descends on many areas of Scotland. According to my Yahoo search, the expression, ‘What’s this, Scotch Mist?’, is a jokey, sarcastic phrase imported from south of the border, which plays on the uncertain state of the misty-ness or rainy-ness of ‘Scotch mist’ and whether it really exists at all.

At this time of year, as we look towards Christmas, and arguably more important in the Scottish social calendar, Hogmanay, it is interesting that this expression should reference some key contemporary themes. I am hardly the first to note that 2016 has been a year of upheavals and that a fog of uncertainty lies over much of what the future holds for us in many spheres. Leading the obfuscation specifically about alcohol policy, which is where I’ve been spending much of my time this year, has been the Scotch Whisky Association (SWA), an organisation whose priority, according to its website is to promote Scotch whisky as ‘a high-quality, much-loved and prestigious spirit drink with a global reputation’ (SWA, 2016), while it continues to front the efforts of global alcohol producers of cheap alcohol, notably ‘own brand’ vodkas, to prevent the implementation of Scotland’s Minimum Unit Pricing (MUP) policy.

According to the University of York (2010), alcohol-related harm costs Scotland an estimated £3.56bn per year, £900 for every adult in Scotland. They also estimate that the cost to the NHS in Scotland is £267 million a year and the cost of alcohol-related crime in Scotland is £727 million a year. DrugScience has consistently argued that alcohol needs to be regulated as a potentially harmful drug; for example, Nutt et al (2010) emphasise that aggressively targeting alcohol harms is a valid and necessary public health strategy.

Arguments presented by the SWA and its backers have included that alcohol-related harms have been reducing and that there is no need for the MUP legislation. In fact, alcohol-related mortality rates in Scotland are one and a half times what they were in 1981 and they have not reduced since 2012. In 2015, 20% more alcohol was sold in Scotland than in England and Wales, mainly due to higher sales of lower priced alcohol through supermarkets and off-licences, particularly vodka (Health Scotland, 2015.)

The SWA and its partners challenge international evidence that indicates that increasing price, reducing availability and restricting marketing are amongst the most effective and cost effective policy measures to reduce alcohol consumption and harm in a population (Babor et al., 2010). They have been recognised as the 'three best buys' of alcohol policy (World Health Organization and World Economic Forum, 2011).

The litigants in the Scottish case have argued that the setting of a minimum price for alcohol would disadvantage the poor. In fact, the reality is that Scots living in the most deprived communities are eight times more likely to die or be admitted to hospital due to alcohol use than those in the most affluent communities (Beeston et al., 2016). Increasing the price of the cheapest alcohol through MUP would reduce health inequalities.

The Scottish Government's Alcohol Strategy Changing Scotland's Relationship with Alcohol: A Framework for Action (Scottish Government, 2009) gave the ‘three best buys’ central prominence and the SNP included plans to legislate for MUP in their manifesto for the Scottish Parliament in 2010. The law passed in 2012 stated that alcohol could not be sold for less than 50p per unit. There was no Parliamentary opposition to the proposal (apart from one SNP MSP who pressed the wrong voting button!).

Since 2012, the implementation of the legislation has been delayed, due to a series of legal challenges, fronted by the SWA. To rehearse all of these would take me well into 2017 in drafting this blog so I’ll spare the reader that. Suffice to say that, after a first appeal in Scotland against the legislation failed in 2014, in 2015 the European Court of Justice (ECJ) confirmed that EU Member states should determine both the level of protection they wish to afford in protecting citizens’ life and health, and the means by which this level of protection should be achieved. The ECJ referred the case back to the Scottish Courts, requiring them to determine whether other measures are capable of protecting human life and health as effectively as MUP, while being less restrictive of trade in those products within the EU.

In October 2016, the Scottish Court of Session recognised that ‘the fundamental problem with an increase in tax is simply that is does not produce a minimum price’ (Court of Session, 2016). For example, Copy this linksupermarkets and other retailers can sell absorb tax increases by means such as offsetting them against the price of other non-alcohol products. The Court (2016) concluded that:

Minimum pricing would attain the stated objective of protecting life and health, particularly of harmful and hazardous drinkers in the lower quintile, gauged by wealth, of the population…taxation, on its own or in combination, would not achieve the same or a similar objective. 

The Scottish courts have now supported the Scottish Parliament’s legislation by all means possible. You would think that the SWA and its colleagues would accept this. Not at all. They issued a statement on their website that they held a ‘strong view that minimum pricing is incompatible with EU law and likely to be ineffective’ and that the Scottish court had ‘not properly reviewed the legislation's compatibility with EU law’ (SWA, 2016).

Earlier this week, the Court of Session decided that the SWA can appeal to the UK Supreme Court. Most legal commentators have little doubt that this appeal will fail. Moreover, even previously supportive media have called on the SWA to withdraw.

Let me return to my ‘Scotch Mist’ metaphor and ask, what is really going on now? I certainly don’t believe that the SWA and its supporters believe that they have an ethical position that they can justify. When they signalled in November 2016 that they intended to apply for leave to appeal to the UK Supreme Court, I tweeted the following message, which was ‘liked’ by Douglas Meikle, the SWA’s Head of Alcohol Policy, indicating his contempt for the democratic process:

In challenging MUP in Scotland, I suspect that the global alcohol producers, for whom the SWA is acting, have done their sums. They have worked out, just as tobacco manufacturers have done in the past, that delaying the implementation of effective and inevitable health regulation as long as possible could be less costly than their lawyers’ costs.

I would also suggest that there may be a clue in what they are up to if we cast our view across the Irish Sea to where a new Public Health (Alcohol) Bill, which includes MUP, is facing highly organised opposition by the same companies who are funding the Scottish legal action. The message to the Irish government and governments who wish to regulate for health in ways that might affect Big Alcohol’s profits: do this and you will be in the law courts for years.

The date of the MUP hearing at the UK Supreme Court is not yet known.

Note, I didn’t even mention Brexit. Happy Hogmanay everyone!

Babor, T. et al. (2010) Alcohol: no ordinary commodity. Oxford: Oxford Medical Publications.

Beeston, C., McAdams, R., Craig, N., Gordon, R., Graham, L., MacPherson, M., McAuley, A., McCartney, G., Robinson, M., Shipton, D., Van Heelsum, A. (2016) Monitoring and Evaluating Scotland’s Alcohol Strategy. Final Report. Edinburgh: NHS Health Scotland.

Court of Session (2016). Available here (Accessed, 22 December 2016).

Health Scotland (2015. Monitoring and Evaluating Scotland’s Alcohol Strategy Annual update of alcohol sales and price band analyses August 2015 (Accessed, 22 December 2016).

Nutt, D.J., King, L.A., Philips, L.D. (2010). Drug harms in the UK: a multicriteria decision analysis. Available from: Vol 376 November 6, 2010. (Accessed, 22 December 2016).

Scottish Government (2009) Changing Scotland’s Relationship with Alcohol: A Framework for Action. Edinburgh: Scottish Government.

SWA (2016). Available here (Accessed, 22 December 2016).

World Health Organization and World Economic Forum (2011). From Burden to “Best Buys”: Reducing the Economic Impact of Non-Communicable Diseases in Low- and Middle-Income Countries. Geneva: World Health Organization.

Psilocybin for anxiety and depression in cancer care? Lessons from the past and prospects for the future

This special issue of the Journal of Psychopharmacology contains two landmark studies – the most rigorous controlled trials to date using the psychedelic drug psilocybin, the active ingredient of magic mushrooms (Griffiths et al., 2016; Ross et al., 2016). These were conducted in patients with anxiety and depression and existential distress in the context of having a diagnosis of cancer, and they showed that a single psychedelic experience could produce profound and enduring mental health benefits.

To many people brought up in the Reagan drug war era with the ‘drugs fry your brain’ message, psilocybin may seem a strange and possibly even a dangerous drug treatment of serious mental illness. For this reason, we have asked a number of significant figures in relevant research areas to provide commentaries on the two studies. These experts in the fields of psychiatry, trial design and end-of-life care provide their perspective on the research and its implications for clinical practice. The fact that everyone we approached agreed to provide a commentary, despite short notice, is a testimony to the interest that these two studies have sparked.

The honours list of the commentators reads like a ‘who’s who’ of American and European psychiatry, and should reassure any waverers that this use of psilocybin is well within the accepted scope of modern psychiatry. They include two past presidents of the American Psychiatric Association (Lieberman and Summergrad) and the past-president of the European College of Neuropsychopharmacology (Goodwin), a previous deputy director of the Office of USA National Drug Control Policy (Kleber) and a previous head of the UK Medicines and Healthcare Regulatory Authority (Breckenridge). In addition, we have input from experienced psychiatric clinical trialists, leading pharmacologists and cancer-care specialists. They all essentially say the same thing: it’s time to take psychedelic treatments in psychiatry and oncology seriously, as we did in the 1950s and 1960s, which means we need to go back to the future. As the commentaries point out, much more research needs to be done into optimising this approach, evaluating the breadth of possible target disorders and exploring the underpinning mechanisms. But the key point is that all agree we are now in an exciting new phase of psychedelic psychopharmacology that needs to be encouraged not impeded.

When Albert Hofmann discovered the remarkable mind-altering properties of lysergic acid diethylamide (LSD) in 1943, he didn’t have much trouble persuading his bosses at the pharmaceutical company Sandoz (now part of Novartis) that this drug would play a very important role in understanding the nature of mental illness and potentially providing a very novel approach to their treatment. Through the 1950s and 1960s, Sandoz supplied medical LSD in the form of Delysid that was studied in hundreds of trials in thousands of patients. The US government via the National Institutes of Health funded more than 130 grants in this field. Results were generally reported as positive and encouraging in disorders including anxiety, depression and addiction (Krebs and Johansen, 2012). One of the founders of Alcoholics Anonymous, Bill Wilson, was so impressed by the power of LSD to change alcoholics’ defeatist focus on alcohol and to give them insights into powers beyond themselves that he encouraged treatment research with it.

Having set off this burst of innovation with LSD, Hofmann continued to research psychedelics derived from plant products, and this led to his discovering the chemical structure of active ingredient of ayahuasca (DMT) and magic mushrooms (psilocybin). The kinetics of psilocybin made it a particularly interesting agent to study therapeutically. When given orally, the effects come on in 20–40 minutes and last around three to four hours, a time course much easier to use in the clinic than that of LSD, which can produce effects that last for 12 hours, or DMT, which isn’t orally active and which given intravenously lasts for just 10–20 minutes. Psilocybin also shows a clear dose–effect relationship, and rarely seems to produce ‘bad’ trips. In many ways, it is the ideal psychedelic for treatment trials, which is what Sandoz tried to do when Hofmann characterised it.

Unfortunately, psilocybin got caught up in the backlash against LSD occasioned by the protests against the Vietnam War and the Haight–Ashbury social revolution. So when LSD was banned on the basis of some very dubious so-called research findings of harm, psilocybin and all other known psychedelic drugs became illegal too. There was no evidence of psilocybin being harmful enough to be controlled when it was banned, and since then, it has continued to be used safely by millions of young people worldwide with a very low incidence of problems. In a number of countries, it has remained legal, for example in Mexico where all plant products are legal, and in Holland where the underground bodies of the mushrooms (so-called truffles) were exempted from control.

It is the safety and ease of practical use of psilocybin that has led to it being resurrected in a series of psychological (Griffiths et al., 2006, 2008, 2011), psychopharmacological (Kometer et al., 2012; Pokorny et al., 2016; Vollenweider et al., 1998), imaging (Carhart-Harris, Erritzoe, et al., 2012a; Carhart-Harris, Leech, et al., 2012b; Carhart-Harris et al., 2013) and small pilot clinical studies (Bogenschutz et al., 2015; Carhart-Harris et al., 2016; Grob et al., 2011; Johnson et al., 2014; Moreno et al., 2006). These have provided the intellectual and safety data underpinning the two current studies that are special in that they are the most rigorous double-blind placebo-controlled trials of a psychedelic drug in the past 50 years. Hopefully, the positive findings that they report will act to spur on other researchers in the field of psychopharmacology, particularly in relation to depression, anxiety and addiction – disorders of enormous personal and social costs, and with many patients who still fail to respond adequately to current treatments, as well as to patients with existential distress

For the original article, including bibliography, please click here

How one patch of grass became the UK's first ever decriminalised drugs space

By Fiona Measham and Henry Fisher. A version of this article was published at

Inside a previously unremarkable circle of grass about 10 metres in diameter, a bold new precedent for drugs policy was set in the UK. Pitched on the grass at the Secret Garden Party 2016 festival in Cambridgeshire, was a tent run by The Loop, a not for profit drug and alcohol service. For those few days it was the first ever de facto decriminalised space for possession of drugs in the UK.

Attendees of the festival could come to the tent and hand over to Loop staff a pill or small scoop of powder where it would be tested for content, purity and strength by a team of chemists without any police interference.

A series of up to three different methods of forensic testing typically took 5-15 minutes to analyse a sample. When those using the service came back to collect their results, they were given individually tailored, free and confidential advice by experienced drugs workers. The risks of their drug and alcohol use were discussed and they could raise any concerns they might have. After being given the results, they were then given the choice to dispose of their drugs. It is important to note that their drug use was neither condoned nor encouraged. This was not 'drug checking' to ensure safer consumption, but harm minimisation. And yes, it was legal. No drugs were returned to users and all drugs were destroyed in the testing process, with police collecting any remnants.

The importance of this development cannot be overstated.While national drug policy is still locked in the deep freeze, the Loop's initiative is the boldest example yet of a progressive evidence-based initiative taking place at a local level. While some police forces have de-prioritised arresting users for cannabis possession or small scale growing, this is the first time any area of the UK, albeit a very small area, has decriminalised possession of all drugs for all users.

This was not an easy battle to win. Alongside the support of the festival management itself, it required the support of the local police, public health and council at all levels, a multifaceted feat of persuasion that The Loop Director and Co-Founder Fiona Measham has been working on behind the scenes for several years. Unsurprisingly there have been several near-misses when trying to implement similar schemes at previous events, each time foiled by unconvinced councillors or truculent public health officials with half an eye on potential reputational damage. "What if someone dies after having their drugs tested on site?" was a regular question posed by opponents. Of course, "what if there are multiple deaths if people can't get their drugs tested on site" was the unasked question left hanging in the air.

Notably, all police forces approached by Measham have been exceptionally supportive of this model of drug testing for public safety - a combination of evidence-based policing and reduced resources means that policing of public events increasingly prioritises harm reduction over criminalisation of possession. This at the same time as national drug policy and local drug services are moving away from harm reduction and increasingly embrace an abstinence-based recovery model of drug prevention and drug treatment. This shift in UK drug policy in recent years has meant that front of house drug testing can sit uneasily with public health officials and councils publicly wedded to zero tolerance festival drug policies.

Clearly the stars aligned for Secret Garden Party and consent was given across the board for it to be the first festival to introduce front of house drug testing to the UK.

The faith of Cambridgeshire police, public health and the enthusiastic organiser of Secret Garden Party, Freddie Fellowes, has seemingly paid off. In total nearly 250 different samples were analysed, with many samples submitted by groups of friends, meaning the actual number of festival-goers who received drugs advice from The Loop actually far exceeded this number. Not bad for an unadvertised first pilot.

MAST is part of a wider research project by Measham at Durham University and the data collected from Secret Garden Party and the second pilot this coming weekend at Kendal Calling festival in Cumbria will be carefully analysed over the coming months. Initial impressions are that the pilot was a resounding success not just for drug users but also for emergency services on site. The value of the service was evident in that nearly a quarter of those who took part, handed their drugs to The Loop to dispose of after finding out that the contents - adulterants or inactive ingredients - were not what they expected. Furthermore they were able to spread the word on site about mis-selling of substances such as anti-malaria tablets as cocaine. While it hasn't yet been quantified, anecdotal reports from paramedics and welfare services on site indicate that they experienced a reduced pressure on their services this year compared with previous years. This then allowed the police to deal with other concerns, such as an influx of organised crime gangs selling nitrous oxide, and paramedics to spend more time on serious casualties.

That small patch of grass also witnessed another small revolution - in people's thinking. Initially sceptical police and paramedics and incredulous partiers saw a different, sensible way of approaching the risks of drug use, and most came away with a different perspective. If such schemes catch on and proliferate, it could be our public and social consciousness that finds itself in an altered state.

Fiona Measham is Director and Co-Founder of The Loop and Professor of Criminology at Durham University. Henry Fisher is Policy Director of VolteFace and testing volunteer at The Loop

I blame Fabric’s closure on this country’s backward drugs policy

A version of this post was published in The Guardian

It seems the London club Fabric has had its licence revoked on the grounds that its management is inadequately controlling drug use in the venue. The immediate incidents that led to this decision were the tragic deaths this year of two young men at the club.

Though it will be months before the coroner’s court tells us the causes of these deaths, it is widely anticipated that drugs will be implicated. And, if so, these are likely to be ecstasy-type stimulants.

The decision to close Fabric has been challenged by Sadiq Khan, the mayor of London, as a blow to the city’s vital nighttime economy, which has lost a lot of venues in recent years. While the death of any young person is a cause of great sadness, I question whether the council and the Metropolitan police’s response is fair and proportionate.

This raises three important questions: did it deserve to be closed; will the closure make young people less likely to come to harm; and how can we minimise future deaths and yet encourage the nighttime clubbing economy?

The first question is one of proportionality. Young people do risky things that often result in harm to themselves and sometimes others, but this doesn’t usually result in the closing of the sites of these accidents. Five young men drowned in the sea at Camber Sands last month but there haven’t been calls to ban swimming at British beaches.

As I detailed several years ago, horse riding (particularly eventing) is statistically riskier than taking ecstasy, but stables are still open, even though one of the UK’s leading eventers, William Fox-Pitt, suffered a significant head injury and was in a coma for two weeks from a fall last year.

The lack of proportionality in the debate appears to be based on the stereotyping of clubbers by the police and public as being too young to make sensible decisions about risks to their health. There is also the added prejudice that the ambience of the clubs they frequent is far too different from that of Badminton or Burghley to be an acceptable source of pleasure.

Will the closure reduce risks? This seems unlikely as it will encourage more “illegal” raves, where security and drug monitoring will be much reduced. Indeed, some such events could even be in part funded by drug suppliers, so the possibility of harm may rise. Evidence for many drugs, such as alcohol, heroin and cannabis, reveals their use in underground markets is much more harmful than when use is properly regulated.

Young people die frequently from acute alcohol poisoning. We don’t stop supermarkets selling alcohol but we do try to reduce harm by checking they are over 18 when they purchase it. Can we apply similar harm-reduction principles to dance venues?

In fact, we already do. Regulations require clubs to have chill-out areas and free water, rules that were brought in to minimise ecstasy–related hyperthermia deaths in the 1980s, and have proved very successful.

In contrast, supply-side attempts to stop ecstasy production, for example through seizures, have increased harm, as these have led to the emergence of more toxic “pseudo” ecstasy tablets containing PMA and PMMA. With these substances, a slower onset of effects often leads to the user “topping up” – and, in the worst cases, to accidental overdose deaths.

Other countries have embraced harm-reduction approaches in clubs with a great deal of success. The most notable example is the Drug Information and Monitoring System (DIMS) system in the Netherlands that allows safe, legal testing of drugs for anyone. It has the added advantage of letting the authorities know when new dangerous variants arrive, such as the Superman ecstasy pills that killed several people in the UK but not in the Netherlands, because there officials were able to warn the public.

In Vienna, a club-based testing system has proved very successful and has inspired a similar model currently being tested on a small scale in the UK.

Fiona Measham, a professor of criminology at Durham University who is behind the scheme, is championing harm reduction through a new charity that has conducted safety testing at the Warehouse Project in Manchester and also at two UK festivals this year. Multi-agency safety testing, as its name suggests, is supported by several groups including, most importantly, the local police in Manchester, who have a forward-looking and responsible attitude to young people’s drug use, in contrast to the regressive, backward looking attitude of the Met.

If we really care about deaths in clubs, we should keep them open and make them safe, using a range of proven approaches such as this, not drive them underground.

The poppers ban is a veiled attack on pleasure

A version of this post was published in The Guardian

The new psychoactive substances bill, when it comes into force in the UK in April, will ban the acquisition and sale of all psychoactive substances, whether existing now or to be discovered in the future, except for alcohol, tobacco/nicotine and caffeine. The driver for this draconian piece of legislation is supposedly to reduce the harms of so-called legal highs and to shut down the “head shops” that sell them. The fact that two exempted substances, alcohol and tobacco, each cause much more harm than all the legal psychoactive substances put together is ignored.

Most of the drugs referred to as legal highs by the proponents of the bill are in fact already illegal. The only legal drugs that will be banned by the new act are some new synthetic cannabinoids, weak amphetamine-type stimulants, nitrous oxide, and alkyl nitrite preparations colloquially called “poppers”.

These last two are some of the safest drugs we know. Nitrous oxide has been used for nearly 200 years for pain control and some alkyl nitrites have been a medicine for angina for around a century. Their safety means that the health impact of their ban will be negligible. The Home Office has said it expects the ban will save around 12 lives a year from drugs, so why are they putting so much parliamentary resource into this bill? If deaths were the concern they would ban the gas helium, which is associated with far more deaths each year than nitrous oxide.

The truth is that this bill is a veiled attack on pleasure. In fact the term “psychoactivity” has become a proxy for the term “pleasure”, and the ban of poppers gives the lie to this.

Poppers are not psychoactive – unless you take the perverse view that the headaches they produce are pleasurable. The Advisory Council on the Misuse of Drugs confirmed this, stating that poppers should be exempt from the bill. Its assessment of poppers has consistently been that although they can cause health harms, the frequency and severity of these are too low to warrant control under the Misuse of Drugs Act 1971. This is presumably why the Home Office is pushing for them to be controlled under the new act.

The science behind poppers is that their active ingredient leads to the production of nitric oxide in the body, which dilates blood vessels and relaxes smooth muscles. Poppers are most widely used in male gay sex where the muscle-relaxing properties facilitate anal intercourse.

Why is the government so anti-pleasure, particularly for gay men? Much of the drive to ban legal highs has come from the Centre for Social Justice (CSJ), a rightwing thinktank that has consistently misled the public and government about the harms of legal highs. These claims have been refuted by DrugScience.

One of CSJ’s main attacks is on what it calls the “loosening” of laws on moral values in the past decades, leading to the erosion of the family. The acceptance of homosexuality is one of its main concerns. It is hard not to conclude that the government shares this opinion and that the poppers ban is in fact an attempt to deter – or even punish – men who enjoy having sex with men.

This is the conspiracy theory explanation, but we must also consider that the government is confused. It may think nitric oxide is the same as nitrous oxide. Confidence in its reasoning is not encouraged by the fact that at the first reading of the psychoactive substances bill, government spokespeople several times referred to a ban on nitrates, which are fertilisers, not nitrites.

Whatever the reasoning behind the popper ban, it is fundamentally flawed. Poppers should be removed from the psychoactive substances bill, though it would be much more honest to scrap the whole legislation as it is so lacking in justification and logic.

The UK needs common sense about ketamine

A version of this post was published in The Guardian

Ketamine is a unique anaesthetic and analgesic that has unfortunately become a popular and harmful recreational drug. Last year, in an attempt to reduce recreational use, and on the recommendation of its Advisory Council on the Misuse of Drugs (ACMD), the UK government decided to ban all ketamine-like drugs (analogues) and also put ketamine itself under greater controls.

These changes were opposed by many scientists who saw the analogue ban as anti-scientific, and by many doctors and vets who feared that the greater controls would reduce ketamine use with consequent increase in patients suffering. Our fears turned out to be true. For example, the Glastonbury festival medical team who use ketamine for emergency anaesthesia (eg for burns) were last year denied supplies.

The increased restrictions also failed to take account of the advances in prescribing options provided by the Patient Group Directive legislation, which improves access to vital medicines by allowing trained nurses and other practitioners to prescribe. On Tuesday, the Home Office was told by the ACMD of this oversight, and hopefully the regulations will soon be changed to allow ketamine to be used optimally.

These issues highlight the perverse damage that can occur with the current simplistic legal-based approaches against recreational drug use. They damage research and harm patients, yet have little if any effect on recreational use. Now the misuse of ketamine in some other countries could lead to an even more outrageous decision: the banning of ketamine as a medicine world-wide. The UN Commission on Narcotic Drugs (UNCND) is proposing this at its next meeting in March. This recommendation is being pursued despite opposition from the World Health Organisation that argues ketamine is a vital medicine. Ketamine is the only anaesthetic that does not cause respiratory depression and one that has proven utility in emergency situations, war zones and in surgery for children. This is not the first time that the faceless “war on drugs” bureaucrats in the UN are trying to get a drug banned to justify their existence – but surely it must be the last?

The prospect of denying the long-proven therapeutic benefits of ketamine to people, particularly children in pain, is one I am sure we would all find abhorrent. We need to remember that because many countries blindly follow UN guidance to ban all strong opioids under UN conventions, 80% of the world’s population doesn’t have access to adequate opioid analgesia, one of the great socio-medical scandals of the past century.

Ketamine also has a major and growing role to play in the control of patients with chronic pain. Moreover ketamine is probably the most significant innovation in the treatment of resistant depression in the past 40 years. It can produce rapid remission of symptoms in suicidal patients and is also being tested in treatment-resistant PTSD.

To stop the clinical and research use of ketamine would be madness but this is what would happen if the UK approves and implements the UNCND recommendation. This would mean that every doctor and hospital that wished to use ketamine would need their own special licence to do so. We know that only four hospitals in the country have such a licence and to get one costs about £6,000 and takes a year or more.

The idea that banning ketamine will stop recreational use is ludicrous, given that similar bans on heroin and cocaine have not impacted misuse. Unless our scientific and medical leaders stand up to the UNCND, researchers and patients will suffer. We need to remember that the UK medical community successfully lobbied the government to reject the 1961 UN recommendation to ban heroin when many other countries went along with it and so eliminated it as a medicine. UK patients have benefited from this powerful painkiller whereas patients in other countries have suffered. We can insist that common sense over ketamine prevails and that our medical leaders demand a similar exemption be applied to ketamine in the UK if the UN proposal is endorsed.

But we should do more. It is time to stop the UNCND pursuing its failed “war on drugs”. This serves its goals of maintaining its significant international profile and job security, but it has been a costly failure in terms of the rest of humanity, particularly because of the perverse effects to deny proven pain-control treatments to much of the world’s population. Surely it is now time for the UK, one of the founders of the World Health Organisation and a leader in international health policy, to rectify this cruelty: stopping it worsening by opposing the ketamine ban would be the first step.

The Superman pill deaths are the result of our illogical drugs policy

A version of this post was published in The Guardian

The past week has seen a number of drug disasters in the UK, one of which is the unexpected deaths of three men, two from Ipswich and one from Telford. They all appear to have taken a drug called PMA (para-Methoxyamphetamine). We presume that they did not know this was what was in the pills bearing the Superman logo that they bought – it seems likely they thought it was ecstasy (MDMA). PMA and its close relative PMMA are not new drugs; they were made in the 1950s and tested for beneficial mood effects then. However, they didn’t provide a clear positive effect so were discarded, though were made illegal under the UN conventions.

They have in the past few years re-emerged as a toxic surrogate for ecstasy. In this period they have been responsible for more than 100 deaths in the UK, and now the majority of deaths that the media report as being due to “ecstasy” are, in fact, caused by PMA and PMMA.

Their re-emergence is directly due to the international community’s attempts, via UN conventions, to stop the use of MDMA by prohibiting its production and sale. As the earlier UN drug control conventions were clearly not working, in 1988 a further attempt to limit drug use by impairing production was made by banning a number of precursor chemicals. One of these is safrole, the precursor of MDMA. In 2010 there was a massive seizure of 50 tonnes of safrole in Thailand. This did significantly dent availability for MDMA production, so chemists looked for an alternative source of a suitable precursor. Aniseed oil seemed the ideal alternative, as it is chemically very similar to safrole, so this was used. Unfortunately the product that results from using the MDMA production process with aniseed oil is PMA or PMMA. Hence these substances only exist because of the blockade of MDMA production. That in itself wouldn’t particularly matter if they were not more toxic than MDMA.

PMA/PMMA are significantly more toxic than MDMA for three reasons. First they are more potent, up to 10 times so. This means that a user who is typically safely using MDMA at a dose of 80mg per session will be taking the equivalent of 800mg of MDMA if they take 80mg of PMA. Secondly, PMA works more slowly than MDMA so when users don’t get the expected effects of MDMA about 30 minutes after taking the drug they think they have been sold a weak lot and may take another dose to make up for this. Then, when the effects of PMA kick in at around two hours, they have taken far too much. Thirdly PMA and PMMA are not pharmacological equivalents of MDMA. They have very different actions, which is why they were discarded after first testing. Their major problem is that they block the actions of the brain enzymes that offset the desired effects of serotonin and dopamine release that PMA/PMMA produce. This then massively accentuates their toxicity as the brain can’t compensate for the increase in serotonin so users can develop serotonin syndrome. This is a toxic reaction that elevates body temperature to a dangerous, and in some cases lethal, level.

The emergence of the more toxic PMA following the so-called “success” in reducing MDMA production is just one of many examples of how prohibition of one drug leads to greater harm from an alternative that is developed to overcome the block. This first became obvious when the US pursued alcohol prohibition in the 1920s and many switched to hootch, which was illicitly distilled ethanol, and some even to methanol, both of which are more poisonous than regulated alcohol. The banning of smoking opium led to the increased production and injecting of a more potent and dangerous opiate, heroin.

There are several proven ways we can we stop this rising tide of PMA/PMMA deaths. One, well established in the Netherlands, is to make testing facilities available to the public without fear of prosecution. This serves not only to warn the users when they have purchased something that wasn’t what they were expecting but also allows the state to monitor the emergence of new, possibly more toxic recreational drugs and put out warnings. A more radical approach as explained by Transform would be to make safe doses of pure MDMA (eg 80mg/day) available to registered users in a regulated fashion, for example, via pharmacists.

In the meantime we should accelerate the testing of seized tablets and make public their contents and strengths on internet databases, so that all users can check what they might be taking. This kind of testing to provide knowledge of drugs in use locally has been pioneered at some clubs and festivals by Professor Fiona Measham of Durham University, and should now be rolled out nationally. Visible public information about tablets, their contents and dosage is used to reduce harm in Ibiza. Finally, let’s stop pretending that these PMA deaths are unexpected effects of rogue “ecstasy” and tell the truth: they are a consequence of our current illogical and punitive drug policy.

“Ravaged by drugs”? Let’s spread facts, not fear; science, not stigma

Today the MailTelegraph and others have been featuring the vile and dehumanising "More than Meth" campaign, which invites us to gasp and be disgusted by the faces of Americans arrested for drug related offenses. The campaign shows mugshots of individuals chronologically as their appearance changes.

Unsurprisingly, the ghoulish coverage of this stigmatising campaign omits small-print disclaimer used by its creators that "The deterioration seen in consecutive photos is not necessarily the result of drugs or addiction..." and that "All persons are considered innocent of the crimes they were arrested for until proven guilty".

The uncritical comments below the coverage of this ‘story’ on the Mail Online and elsewhere are pretty depressing, including low points such as “Ewwwww...” and “... it's not [sad], it's their own bloody fault”. The number of people arrested for drug offenses in America per year is not that far off the total circulation of the Daily Mail; out of a pool of one and a half million people, you can presumably select a dozen mugshots that tells any story you want;- that methamphetamine is an elixir of youth, that heroin use leads to steadily curlier hair. Similarly, someone with a different agenda could cherry-pick Mail Online comments from individual readers to form chronological time-series that appeared to show that exposure to Mail articles leads to increasingly reactionary and ignorant views... but that would be equally meaningless.

It is true, and let’s be absolutely clear, that use of methamphetamine, heroin and cocaine (and much more commonly alcohol) can become problematic from the beginning or after years of use, that a significant minority of users can find their control slipping despite seeing damage occurring, and that chaotic drug-centred lives, (especially when eating, sleeping and self-care get neglected) can lead to abnormally fast ageing, collapsing health and death. In fact, crack cocaine, heroin and methamphetamine, followed by alcohol, ranked as the four drugs with the greatest associated harm to the typical user (alcohol leaps ahead in terms of total harm caused due to its vastly higher prevalence) in the ISCD’s famous objective assessment of Drug Harms in the UK.

However, an individual's deteriorating health cannot simply be put down to the illicit substances they use, and separated from context, including the purity of what they use, the way they use it (are they addicted? Do they inject?), their individual biology, their life history, their social environment and the political environment. If it was as simple as these drugs being fundamentally highly toxic substances that automatically make your teeth drop out and your skin break down, amphetamines and opiates would not be widely used and valued as medicines.

Heroin and methamphetamine molecules have fixed physical properties like mass and solubility, and they have intrinsic pharmacological properties, i.e. they cause predictable effects on heartbeat and brain activity according to the dose. But neither they nor any other drugs have a predetermined property that they always take over and wreck the lives and health of everyone who tries them. In reality only a minority of drug users become addicted to drugs, doing so despite their best efforts to cut back and stop using. Addiction is not a failure of moral fibre. Put another way, drug use is neither necessary nor sufficient to tell the story of how any one of the people featured in this campaign reached such a low ebb in their lives. 

The most obvious contextual factors this campaign chooses to gloss over are social and political ones. These photos are not, say, a random sample of people who have used illicit drugs in the past year, which I don’t imagine would be easy to distinguish from a sample matched by age and background. All the photos are mugshots of people getting arrested for drugs offenses; by definition people undergoing harm. Being in and out of prison and having a permanent criminal record does not make it any easier for people with drug use problems to get a steady job and a stable lifestyle, get their problems in hand and look after themselves. Users of methamphetamine and other drugs are very often at the bottom end of America’s ever-more unequal income distribution, and numerous factors exclude them from accessing addiction treatment and health and welfare services.

Alleged drug use by the subjects of these photos seems to have become a convenient excuse to sidestep the question of why the richest country ever allows millions of its citizens to live precarious existences without a decent safetynet. Rather than questioning this, it seems that the campaign is instead telling us “Don’t make yourself worthless like these people have!” If the individuals pictured were considered to be real people with families and futures who could be helped and supported to help themselves, it might be harder for this campaign’s creators to morally justify these stigmatising, humiliating photos which themselves must negatively affect the life-chances of the subjects.

None of this criticism should detract from legitimacy and importance of running campaigns that inform people that by minimising or better still avoiding use of these particularly risky drugs, they can minimise or avoid the risks of collapsing health and death. In the opinion of the ISCD, the success of drug information campaigns should be judged not by their ability to shock or to go viral as ‘clickbait’ in newspapers and blogs looking for a free way to generate traffic, but by their honesty and their effectiveness in reducing the total burden of harm associated with drug use, including the harms of criminalisation and stigmatisation.

The ISCD is a volunteer-led organisation, (neither I nor anyone else in our scientific committee get any money for our time) and funding is tight. Since methamphetamine isn’t widely used in the UK, we’ve so far not published one of our evidence-based information pages on it. But we’ll try to get one up on the website within a month, and you can help us by donating, which pays for office costs and supports our mission to get objective, harm-reducing information out there. 

In the meantime, if you want to find out more on the science and mythology of methamphetamine, you can read a deeper evidence-based critique of meth hysteria from Prof Cart Hart and colleagues here.

Michael Le Vell – double standards over the ‘use’ and ‘abuse’ of drugs

ISCD volunteer Richard Clifton takes a look at drugs in the news.

In recent years, it seems that Coronation Street is never very far away from a drug scandal, and now Michael Le Vell has become the latest in a long line of actors to be suspended from the soap after admitting to snorting cocaine. Craig Charles, Simon Gregson and Jimmi Harkishin have all been written out of the show in the past after being caught with drugs (all the actors have subsequently returned). 

Newspaper headlines talked of Le Vell’s cocaine ‘abuse’ and his suspension was a direct result of hisadmission to the Sunday Mirror on 1st March. However, the actor has claimed to have only used cocaine on two occasions. At the time he was still on trial and under considerable pressure and media scrutiny. These circumstances are not meant to condone his drug use, but the term ‘abuse’ seems to leap to judgement, and the word ‘addiction’ used in the Independent seems simply incorrect. The ISCD always refers to drug ‘use’, rather than ‘abuse’ or ‘misuse’ on principle, because the latter terms are subjective labels, not objective assessments that can be put to any scientific test, like ‘harm’. 

An interesting contrast is apparent in the portrayal of Le Vell’s use of another drug. The actor has also admitted to being an alcoholic for the past thirty years. Le Vell would, he said while on trial, drink up to twelve pints a night and has sought out Alcoholics Anonymous in the past. Using any metric, this level of excessive drinking for prolonged periods of time is likely to have a greater potential to damage and disrupt the lives of Le Vell and the people around him than infrequent cocaine use. Yet upon his acquittal from charges of sex offenses, newspapers pictured him ‘celebrating’ with a pint with neither the judgement or pity that accompany stories of celebs using or addicted to other drugs.

Statements from both Le Vell and his family indicate that he will stop taking cocaine but: “He still likes spending time in the pub with his friends but he’s not doing that as much,” in spite of his alcoholism. The double-standard is striking. The obvious distinction between the substances is their legality, but Le Vell was suspended for medical rather than criminal reasons (it is possessing not taking cocaine that is an offence in any case) and in terms of risks to health cocaine and alcohol are not worlds apart.

The ISCD’s 2010 study in the Lancet, comparing the relative harms of 20 different drugs, ranked alcohol as the most harmful drug tested (scored 72) whereas cocaine was ranked fifth with a score of 27. Alcohol’s higher score is mainly due to the large impact that it has on people other than the user (lost productivity, drink driving, violence) but alcohol and cocaine remain similarly harmful overall even if we just consider metrics that impact the user. Cocaine was found to have a greater addictive potential than alcohol (2.39 vs. 1.93), but alcohol edges ahead on some other factors including bodily damage.

Society would benefit from a more consistent, proportionate, informed attitude to the relative dangers of different drugs.

Figures for UK deaths from legal highs cannot be trusted

A version of this post was published in The Guardian

At the last G8 summit, the prime minister said legal highs are a serious concern and claimed that the UK would lead the world in research into them. But at the same time David Cameron's government has introduced temporary banning orders on several legal highs, thus making this research very difficult. The new drugs minister, Norman Baker, has since rejected the idea of the UK joining in the more balanced approach being proposed by the EU and has set up a working group to explore local options to this so-called "growing threat".

The latest figures on these new psychoactive substances, for 2012, were published as two separate datasets: one from the National Programme on Substance Abuse Deaths claiming 68 deaths, and the other, from the Office for National Statistics, claiming 52. These numbers are tiny when compared, in both relative and absolute terms, with the 80,000 deaths per year from tobacco, the 8,000 from alcohol or even the 1,200 from opioids, but still the media have revelled in the seemingly large increase from the previous year.

DrugScience has looked into these data in some detail, and as explained in our letter published on Friday in the Lancet, on closer examination they look very suspect. For instance, most of the drugs identified as being "legal highs" are not in fact legal. Only 11 of the 68 are currently "legal highs".

Twenty deaths reported by the National Programme on Substance Abuse Deaths are associated with the PMA/PMMA types of amphetamines that have been illegal for over 30 years. These drugs are considerably more toxic than MDMA (ecstasy)and emerged as a direct consequence of MDMA production being restricted by the clampdown on sassafras oil and other precursors. PMA/PMMA drugs are intrinsically more toxic than MDMA, but are sold as ecstasy.

They also have slower onsets of action than MDMA, which can lead users to believe after the first dose that they haven't taken enough; they then take another dose which means that later when absorption is complete they have accidentally overdosed. This is one of many examples of the perverse effects of prohibition: limiting availability of a relatively low-harm drug can lead to greater harms from alternatives. We have advice on the ISCD website for anyone who might come across PMA. These drugs have caused deaths in other countries, particularly Canada, leading to calls from senior health officials to legalise MDMA to obviate the threat of these counterfeits.

The most frequent drug deaths reported by the Office for National Statistics were attributed to GHB (13 of the 52), which was made illegal in 2003 when we were part of the group reviewing its harms for the Advisory Council on the Misuse of Drugs. Among the drugs labelled "legal highs" were anabolic steroids and DNP (a weight-reducing agent), which are not even psychoactive. Intriguingly, according to the Office for National Statistics, there were only four deaths solely frommephedrone, despite it being the most popular stimulant in 2008/9.

The poor quality of the data currently being discussed in the media raises the question of whether this is just sloppy science or whether there has been some attempt to massage the figures to justify the current political focus on legal highs. It is also questionable whether we need two sets of drug-related mortality statistics.

The government and media attention on legal highs distracts from the much more important health issues of tobacco, alcohol and heroin deaths. What is certain is that if the current government review of legal highs is to be taken seriously and lead to health improvements then there must be a proper definition of terms and improved data collection. Moreover the data must be independently audited so the effects of any change in the law can be properly evaluated.

Death by cannabis?

(UPDATE 04/02/2014 - The Metro brought balance to their coverage by publishing letters today from Prof. David Nutt (see picture below) and other readers on the subject of the risks of cannabis. The ISCD will continue to make such media interventions where a scientific perspective is needed, but we rely on your continued support to do so. Thanks for your donations; the more we receive the more resources we will be able to dedicate to this aspect of our work.)

Today, the front page headline on the Metro newspaper read “The tragic proof that cannabis can kill”. Perhaps this splash might lead to some family conversations about drugs. If so, it would be useful now to consider what the sad case of one young mother who died after smoking cannabis can tell us about the dangers of cannabis. I think the answer is nothing. If this upsetting story does at least prod parents into talking to their kids about drugs I hope they might discuss just how to sceptically evaluate and make use of the information we read in the papers.

With scant formal drugs education and negligible public information, our national conversation about drugs is built around the telling of tragic stories like that of Gemma Moss, Leah Betts and Amy Winehouse. Although the facts may be at least part true, these stereotyped stories subtract from rather than adding to the public understanding of drugs. They erode rather than bolster the potential of individuals and the State to rationally recognise and minimise the real harm drugs can cause. These stories misinform even when the facts are ostensibly ‘true’, because the real names, places and dates are slotted into misleading old fairytales about the essential moral evil of drugs, (which are made animate by the stories), and the essential vulnerability and innocence of those (particularly attractive young women) who passively fall prey to them. The types of drugs, people and harm in these stories are not representative of the real burden drugs cause in society. 

I cannot begin to understand the pathologist’s certainty that cannabis killed Gemma Moss, but neither do I wish to contradict him outright. Taking any amount of cannabis, like all drugs, like so many activities, puts some stresses on the body. Cannabis usually makes the heart work a little harder and subtly affects its rate and rhythm. Any minor stress on the body can be the straw that breaks the camel’s back, the butterfly’s wingbeat that triggers the storm. Ms Moss had suffered with depression, which itself increases the risk of sudden cardiac death. It is quite plausible that the additional small stress caused by that cannabis joint triggered a one-in-a-million cardiac event, just as has been more frequently recorded from sportsexsaunas and evenstraining on the toilet

There are good reasons that most of us choose not to use cannabis, and that most of the rest do so infrequently. You can get arrested, some become dependent on it to relax, it can make you cough and wheeze, feel less sharp than you could be, or more anxious, and a cannabis habit can be a barrier to achievement. The risk of sudden cardiac death has no place on the list of sensible reasons to avoid or cut down cannabis use. As with cannabis, there is a long list of reasons someone might want to avoid or cut down on visits to McDonalds for example, but a single freak fatality caused by such a visit is not one of them.

The question of whether cannabis killed one individual may be significant for the family concerned but it is not useful for exploring the essential scientific, political and personal questions about each drug’s capacity to injure and kill. To answer that, you need data from thousands of people, to distinguish harm from freak events. Coincidentally, buried on page 20 of the same edition of the Metro, three lines of text allude to a new study on alcohol that provides a striking example from a study of 151,000 people. It found that one in four Russian men are dead before they reach 55, most of them killed by alcohol.

Scheduling clash: revisiting ketamine (and legislation) harms

It was announced today that ketamine will be reclassified to Class B, up from C. But that's not the whole story.

Drug classification, which determines the penalties for illicit recreational use, makes the headlines. Drug scheduling, which determines the regulations for licensed use by doctors, vets and researchers is the hidden issue here. The proposal is to tighten the regulations on legitimate use of ketamine to the very toughest level, the level used for diamorphine, more commonly known as heroin.
Heroin is a valuable painkiller for dying patients, but needs the tightest controls on secure storage and documenting its movements to prevent supplies going missing, or worse, as the Shipman murders demonstrate. The risks of ketamine misuse or theft is simply notcomparable so this move is disproportionate and unnecessary. Current regulations on ketamine are sufficient. Sensible NHS guidelines already stipulate that where practical, ketamine is to be treated the same as heroin anyway, so the proposed change is not needed. But vets, especially small local and agricultural vets operating out of buildings without purpose-built drug storage rooms may be hit hard by overzealous restrictions. 
The consequences of burdensome or totally obstructive rules on the legitimate use of ketamine will of course not only inconvenience vets, but may cause harm and suffering to animals when vets are less able or willing to make use of ketamine, or to afford to upgrade their drug storage facilities to stock it. Vets rely on the unique properties of ketamine as safe anaesthetic for many species. Also, research projects on wild animal populations (such as the badgers of Wytham Wood) sometimes utilise ketamine as a low-risk way to allow measurements to be taken while causing minimal stress to the animal. Such research has proved essential for understanding and protecting British wildlife, for example by collecting evidence on the impacts of climate change, and the feasibility of TB vaccination. It is very important for conservation efforts that misguided regulations do not put such vital work in peril.
The proposal to reschedule ketamine seems simply to be an automatic move to match the reclassification, rather than a considered decision to reduce harm. Before ketamine became a popular recreational drug, diversion of legitimate supplies may have been a significant source to the illegal market. However, ketamine is now manufactured and imported in large quantities for the illicit market, and diverted legitimate supplies play no meaningful role.

Help me in my ambition to be uncontroversial

I’m very grateful for having been awarded the John Maddox prize. The award has caused me to reflect on the role of science in the public discourse, and evidence in politics, to ask what Standing up for Science means.

When I am invited to talk on the radio or in a debate, sometimes it seems as if I am there to represent one pole of a dichotomised debate. This isn’t always a comfortable position for a scientist to be.  There are a few topics where I am happy to be contentious, but more typically I find that there is no relation between the statements I think are radical and those that actually provoke controversy. I can’t complain if people disagree with a moral or political stance, but I worry when it is factual statements about the harms of drugs or the efficacy of policy that are received as controversial by interviewers and listeners. It’s controversial to point out that the risks of some Class A drugs, such as LSD and ecstasy, are simply not comparable to those of heroin or methamphetamine. It’s controversial to suggest that “sending messages” by toughening classification has no pronounced or predictable effects on the prevalence of drugs like cannabis or ketamine. It is controversial to think that interventions that result in a fall in the numbers using a particular drug cannot be assumed to be successful in reducing net harm. This phenomenon, where truth is taboo, is the hallmark of topics where progress is needed in improving public understanding.   

Drug science happens to be the field in which I do most of my work, but the change I’m hopeful of seeing would necessarily be wider-reaching. Improved public literacy in critical and scientific thinking is a desirable end in itself, but I think that the benefits could be quite profound, as any rewards attached to mythmaking by politicians and journalists recede, and the costs of misrepresenting science grow. Those who stand up for science risk being misconstrued as advocating for something akin to a scientific dictatorship, where their advice is never challenged. Actually, my vision for the role of evidence in the political debate is quite different; what I would like is a shared understanding about when any views or feelings have an equal claim to be considered, in contrast to questions of fact, things that can be framed and tested as scientific hypotheses. How much more productive might these discussion be if we could start from a consensus reality, and a shared assumption that any intervention we should make should have real-world effects? This was summed up by Dr Ben Goldacre on a science comedy programme this year (18.40). He said “It would have been nice to see politicians say ‘Look, I understand [what the evidence shows about the relative dangers of drugs], … but I just think, regardless of the real world impact, I just want drugs to be illegal. I just feel, morally, it’s just nice that the country sends out a message, just says this stuff is wrong, and actually I don’t care if the impact of that is to increase the total amount of harm.”

For better or worse, science and society are interconnected. It is up to scientists to step out of the lab and stand to say that using – or at least considering - evidence in public policy shouldn’t be controversial. It's something that we at the ISCD have worked tirelessly to correct. The only way we can continue to be independent and speak out for science is with your help. Please donate today.



Sense About Science: The John Maddox Standing up for Science Award

Why David won the John Maddox Standing up for Science Award

Our cultural imagination features some odd and rather unflattering stereotypes of scientists; the socially awkward oddballs out of touch with reality, or the maniacs in blood-stained lab coats you may have encountered this Halloween. Thankfully for the ISCD, with its mission of promoting an evidence-based public discussion around drugs, Professor Nutt defies these stereotypes rather more than his name would suggest. David is in his element in his laboratory and in his clinical work, but equally stellar when speaking to young festival-goers at the Secret Garden Party festival and giving evidence to the Home Affairs Select Committee. He demonstrates on a daily basis that evidence is not irrelevant or threatening, rather, that knowledge is for everyone, that engaging with evidence benefits society. That is standing up for science. David has been at the forefront of his academic field, and improving his patients’ wellbeing for decades, but to understand just how fitting this accolade is, we need to consider the last four years.

Exactly four years ago, Jon Gaunt wrote the following in Britain’s most popular newspaper after David had commented on the relative dangers of illegal drugs such as cannabis and ecstasy compared to alcohol and tobacco. “He wants to reclassify all drugs on a “harm” basis and in an academic sense he might be correct. But we are not talking about a society that is only confined to the lofty intellectual towers of a university campus… It's perfectly acceptable for Nutt to have these discussions in the cosseted world of academia but it is totally irresponsible for him to pontificate in public and in his position as Drug Tsar. He must be sacked immediately.”

David had, it seems, broken an unwritten rule stating that the public are vulnerable to reality and must be protected from the dangers of scientific evidence around drugs. If this quote sounded silly then, it is staggering now. David was indeed sacked, but instead of being humiliated into silence, he founded the ISCD and has redoubled his efforts to stand up for science, to bring the discussion of drugs out of that “cosseted world of academia” and into the public domain.

Perhaps not many people realise that when he was sacked, David did not lose a government salary and pension; members of the Advisory Council on the Misuse of Drugs are unpaid public servants. The ISCD follows the same model;- he and the other 20 Committee members contribute their time for the public good without financial reward. The ISCD is a lean machine, with only two part-time staff on the payroll. All donations go straight to our day to day operation and pursuing our projects. With a huge support-base in and outside the scientific world, and plenty of plans ready to be put into action, funding is the only limit to what we can achieve. If, like us, you admire David’s generosity in dedicating his time to standing up for science, please stand with him by donating to the ISCD. Together, we can make the evidence matter.

Sophie Macken
Director, ISCD

“Think cannabis is harmless?” No. Does anyone? But what about propagating drug hysteria? Is that harmless?

A week ago, the Daily Mail published a story entitled “Think cannabis is harmless? It drove this grammar school boy insane – then killed him”. This is not the first time that the Mail and other newspapers have used personal tragedies to generate panic about cannabis, particularly related to psychosis, and particularly aimed at concerned parents. In the past, the ISCD and other voices who challenge drug misinformation have hesitated from getting involved, as it seems rather distasteful to engage in a debate about evidence over the body of a young man. However, this has allowed the Mail and others to go unchallenged in their willingness to exploit their readers, grieving families and the deceased themselves. They sell wild speculation and morbid sensationalism dressed up as a heroic crusade against enemies in our midst. The headline alone takes aim at two insidious foes for readers to fear and hate; the army of straw men who think that cannabis is harmless, and the drug itself, which becomes personified as a killer. 

You do not need telling that newspapers are not scientific journals, nor that many journalists are talented in creating eye-popping nonsense. That’s not news. What we want to point out is that these stories are not just a diversion from the real issues; they may themselves be harmful. Whilst posing righteously as exposing the threat of cannabis-induced psychosis, the Mail may in fact be contributing to the problem, through their effects on public understanding and political tides. To explain how, we need to explore the evidence of links between cannabis and psychosis. 

Cannabis is associated with psychosis (a symptom) and schizophrenia (an illness where this symptom is persistent) in complex, contradictory and mysterious ways. The evidence does demonstrate various links that we all should all be aware of, especially cannabis users and parents. However, the evidence doesnot support anything like the level of fear propagated in the media.

Whilst someone is actually ‘stoned’, the principal psychoactive component of cannabis, THC, can sometimes have unwanted psychosis-like effects, such as anxiety and paranoid delusions. This is a reason that many people try the drug and don’t like it; but transient paranoia isn’t the same as schizophrenia. Persistent drug use of any kind may seriously complicate and worsen pre-existing mental health problems, and the use of cannabis seems able to exacerbate symptoms in a person with an illness like schizophrenia, or latent vulnerabilities.

On the other hand, the second key component in cannabis, cannabidiol (CBD), has powerful antipsychotic and anti-anxiety properties, so people with schizophrenia, or teens predisposed to psychotic symptoms may feel relief from consuming cannabis. Paradoxically, this self-medication is very likely to be counterproductive in the long-run because of the THC content, and so vulnerable young cannabis users should be given this explanation, and positive support to minimise or stop their use. The paradox of short-term relief versus long-term exacerbation shows the need for great sensitivity to the experiences of young cannabis users with mental health problems; they may not be being delusional and selfish by using the drug as the Mail implies, but simply doing what, in their experience, helps. 

Several studies have suggested that regular, long-term cannabis use is one of a number of environmental factors that, in combination with certain genetic predisposing factors, may significantly increase a young individual’s chance of experiencing psychosis and developing schizophrenia. However, numbers of people being diagnosed with schizophrenia remained stable over time during which the number of cannabis users increased and average strength rose significantly. There are clearly nuances that remain to be understood, but despite this uncertainty, we can entirely rule out the possibility that cannabis causes a level of risk of schizophrenia that would warrant the media coverage of the issue.

Cannabis use is fairly common (around 1 in 3 have tried it), and use typically begins in teenage years and young adulthood. Schizophrenia is fairly rare, (about 1 in 200 will be diagnosed at some point in their lives) and also typically begins in teenage years and young adulthood. It should be noted that when a condition is rare, less concern is warranted by an increase in risk, compared to if a condition is common. For example, a doubling in the risk of cancer or heart disease, very common conditions, should really worry us. A doubling of the risk of being struck by lightning shouldn’t really scare us at all. 

A doubling in the risk of psychosis, Robin Murray’s rough estimate for the maximum increased risk of heavy cannabis smoking, lies somewhere in between; far from meaningless, but certainly not a major public health catastrophe. Based on a similar estimate of risk, it has been calculated that very roughly, the chance of a 20 to 24 year old man (the group at the very highest risk) developing schizophrenia this year will be raised from about 1 in 3,100 to 1 in 1,900 if he is a heavy cannabis smoker. This is not, in our view, even the most serious risk of cannabis. Roughly one in ten cannabis users are addicted; they have lost some degree of control over their use. Heavy cannabis use before adulthood can interfere with education and intellectual development, impacting on learning and employment opportunities. 

The other major negative impact of cannabis use is that of getting a criminal conviction for possession or other minor cannabis offences. These have a profound impact on future employment and travel opportunities, disproportionately affect the UK minority ethnic population, particularly black young men, and may preclude them from serving as police officers, teachers, nurses and politicians. Those, in our view, are far far more significant problems, but perhaps they are less suited to creating sensation than the fear of one’s children becoming “insane”.

In comparison with this uncertain 2-fold increase in psychosis risk from heavy persistent cannabis use, the risk of lung cancer from heavy and persistent cigarette smoking is increased by about 25 times. Now that is a public health catastrophe. Cannabis smoke can irritate lungs, but is not definitively linked to lung cancer. Cigarettes are moreover a particular catastrophe for people with schizophrenia, who smoke at vastly higher rates than the general population, a major reason they live shorter lives on average. But the association between legal tobacco and psychotic illnesses, or indeed suicide, is not of much interest to the media. 

If cannabis use does increase the risk of schizophrenia, this means that cannabis use is causing some ‘extra’ cases that wouldn’t occur if cannabis didn’t exist. However, unless cannabis turned out to be causing a much higher risk increase than the most alarming scientific estimates, it remains true that the majority of the young people who smoked cannabis and developed schizophrenia would have developed the illness in any case. By analogy, consuming even low amounts of alcohol is causally linked to an increased risk of breast cancer, but most women who develop the cancer and also drink alcohol would have developed the cancer anyway. The implication of this key fact is that when any particular case of schizophrenia is definitively blamed on the cannabis use of that individual, such as in the Mail’s article, this is always misleading speculation (and thus, on the face of it, always in breach of the codes of press standards to which the Mail is committed).

A cannabis-using young person experiencing psychotic symptoms, or diagnosed with schizophrenia, should be told that cannabis is likely to worsen their condition, may have been a factor in causing it, and be strongly encouraged and supported to give up the drug. To instead dishonestly affirm that their choice to use cannabis brought about their own illness is cruel victim-blaming. The Mail has a long history of promoting the health benefits of daily alcohol consumption; but we are unaware of any article published by the Mail that categorically blames a woman’s daily drinking for her death from breast cancer.

So is this myth-making about cannabis and psychosis a harmless form of tabloid titillation? We think not. When parents and even doctors become hysterical about a vulnerable individual using cannabis, attribute blame and have lots of arguments with them, for all their good intentions it may be making the situation worse. As we have seen, cannabis use is at worst one risk factor amongst many, and that cannabis containing CBD may in the short-term offer relief from psychotic symptoms and anxiety, even whilst it might make things worse in the long-term.

We are not saying that parents should just ‘chill out’ about their children using cannabis and especially not if they have a pre-disposition to mental health problems. However, people with schizophrenia struggle with a gap between their reality and the consensus reality, and often don’t know who to trust. So to treat as delusional that person’s valid experiences that cannabis helps ease their symptoms is not going to help. Research shows that the stress of criticism and stigma within the family and in the wider social environment worsens the course of schizophrenia, and can lead to suicide, whereas a stable, warm environment can improve the prognosis and protect against suicide.  

Secondly, the media frenzy over cannabis and psychosis has had harmful and counterproductive political consequences. When he was Home Secretary, David Blunkett was brave enough to listen to what experts had been saying for decades, ignore hostility in the press, and downgrade cannabis to Class C. Following this move, cannabis use continued to decline steadily, (legal classification having no significant impact on cannabis use), the Home Office celebrated saving 199,000 hours of police time,  whilst fewer people suffered the harms of criminalisation. However, from the announcement of reclassification onwards, the Mail and several other newspapers produced a stream of spurious articles about skunk cannabis and schizophrenia, alleging that Blunkett’s move to “soften the law” was putting young people’s mental health at risk. Predictably, the pressure was too much and in 2008 Jacqui Smith announced that she would put cannabis up to Class B again, a decision she now regrets

Since then, the Mail has persisted in misleading their readership, even in 2011 asserting in a headline that “Just ONE cannabis joint can bring on schizophrenia”. To once again stress the gulf between this claim and reality, based on estimates discussed above it has been estimated that to prevent one case of schizophrenia in men aged 20 to 24, about 5,000 men would have to be prevented from ever smoking cannabis. 

This year, a fascinating analysis was published of hospital admissions recorded for ‘cannabis psychosis’ over the brief period when cannabis was in Class C. Admissions fell when cannabis was made Class C and rose again when it became Class B. The lead author of this research, Ian Hamilton, points out that a causal link cannot be definitively made. Even so, after this finding, how can the Mail and others maintain their position that it is their heartfelt concern for the mental health of our children that justifies tough penalties for cannabis possession, and that those who argue against criminalisation recklessly endanger young people’s minds? Whilst they dedicate pages to emotive anecdotes of cannabis victims, wildly misrepresent research on mice and report unpublished research when it can be distorted to fit their view, they unsurprisingly did not cover this peer-reviewed analysis.

It is bitterly ironic that those who set themselves up as a bastion against insanity-inducing cannabis may have some responsibility for the current situation, where vulnerable cannabis users only have access to the types of cannabis which pose the highest risks to mental health. The UK cannabis market has evolved under the pressures of tough enforcement. Instead of importing hashish and outdoor-grown cannabis, products high in cannabidiol (CBD), most is now grown indoors here, and contains far less CBD and much more of the psychosis-promoting THC. If the Mail wishes to crusade in the interests of families impacted by schizophrenia, they could instead support research into the potential use of CBD as an antipsychotic, one with none of the nasty side-effects of currently available options.

Tragically, it seems likely that the harmful consequences of promoting criminalisation, instead of education, to ‘send messages’ on drugs fall disproportionately on the very same people most vulnerable to any increased risk of psychosis that cannabis may produce. They are not the demographic of cannabis victims which the Mail focuses their sympathies on. A cannabis-using young person who is black, male, an immigrant or child of immigrants, lives in an urban area, and has an unstable home life has many of the risk factors for psychosis, and is precisely the demographic most likely to be arrested for cannabis possession. The disproportionate laws for which the Mail has lobbied, supposedly to reduce the harms of cannabis, just compound the harm falling on the most vulnerable.

The ISCD will critique, debunk and praise more drug-related stories in the media. We hope you will come back and read, and perhaps we’ll see fewer nonsensical drug-related articles like this being published, and journalists using their talents to inform rather than mislead.

The Government’s proposal to curb drug-driving is a car-crash

A short version of this blog post was published in the Guardian

I don’t know about you, but I find that the old “Would You Rather?” game helps liven up long motorway journeys. Here we go…

Would You Rather that the car ahead of you was driven by Paul, who just knocked back the hair of the dog at the motorway services pub before merging back into your lane from the slip road…

Or Would You Rather be behind Rob, who is alert, has his eyes on the road, but shared a cannabis joint earlier on in the day?

Now when I tried this question out earlier, the first answer I got was “That’s a plainly leading question, not a balanced dilemma. You clearly don’t know how Would You Rather works”.

The correct answer I’m looking for to set up this article is “I’d definitely rather drive behind Rob. He’s probably as clear-headed as I am if a few hours have passed since the joint. Half-drunk Paul might be dangerous though. And what’s a motorway services pub? No-one would allow that”.

The Government see things differently and have plans afoot.  Regulations preventing alcohol sales on Highway Agency sites, they believe, are stifling the development of motorway branches of Wetherspoon and similar big pub corporations and should probably be removed. If Paul can stay just south of our generous legal drink-driving limit, (not that anyone will be breathalysing people as they leave the pub) his drug use is an essential part of the economic recovery. This Government prides itself on cutting regulatory red tape. I just hope that less red tape at the roadside doesn’t mean more of the fluttering blue and white kind bearing the word ‘POLICE’.

What about Rob? Under Government proposals, if a microgram of THC (from cannabis) can be found in a pint and a bit of his blood, (enough to be sure he hasn’t simply walked too slowly past a cannabis smoker), then he should be prosecuted as a drug-driver. Whether or not Rob is in possession of cannabis, actually intoxicated, or in any way a danger to road users, is immaterial. The Government have announced that they want a “zero-tolerance approach” to drivers whose bodies contain definitive traces of any one of a blacklist of 8 controlled drugs.  They openly state that they don’t want to take a consistent "risk-based" approach to drivers using drugs; an approach that aims to discourage and punish those who drive when their blood contents suggests they are unfit to do so; they would prefer to use the Road Traffic act to get “tough” on people who test positive for an arbitrary selection of the wrong drugs, and so “send a message” to us all about the unacceptability of drug use. Some drug use. The “risk-based approach” as recommended by their scientific advisors is fine for alcohol, sleeping pills, morphine, just not for cannabis, cocaine, MDMA and 5 others. This is, they say, to avoid sending “mixed messages”.

I probably don’t need to tell you that “sending messages” of any kind isn’t really what the Road Traffic Act is supposed to be for. Evidence abounds that messages of toughness or liberality expressed by drug laws have no clear effect on levels of drug use. Disproportionate toughness will not prevent car wrecks, but lives and careers will be wrecked through criminalisation. Yes, driving when properly ‘stoned’ is one of the only ways cannabis can kill, and needs to be tackled. A risk-based cannabis-limit can do that. Zero tolerance to drivers who ever use cannabis is more likely to make things worse. In US those states where medical cannabis has been legalised, there are fewer deaths on the road, probably because people switch to cannabis from alcohol. Both drugs dangerously impair driving, but they are strikingly unequal in their relative risks. In a dataset (France 2001-2003) where an equal proportion of drivers have alcohol in their system as cannabis, the drinkers cause more than ten times as many fatal crashes.

Changes to the Road Traffic Act should be directed at maximising its fairness and functionality; “messages” are best sent through education not legislation. The extra enforcement costs of pursuing not just intoxicated drivers, (the ones who put us all at risk), but any drivers who test positive for traces of the blacklisted substances, will be a big drain on resources. On the other hand, following the evidence-based approach instead, by the government’s own estimates is much more favourable, with the value of preventing casualties more than outweighing the costs of enforcement.

Once again, the Government commissioned a team of scientists to set out the facts and make evidence-based recommendations, and then resolved to stick with their own prejudices. The Government’s plan, and two alternatives (one being to accept the expert recommendations in full), was set out in a Government Consultation which has now closed, but you can still have your say in this “would you rather” game that actually matters by contacting your MP. Their assent is needed for this amendment to the Road Traffic Act to be adopted. You’ll find more details in the ISCD's submission to the consultation here

Of course the Government decided that its arbitrary zero-tolerance drug blacklist would be incomplete without including a drug unparalleled in its fearful symbolic potency; LSD. What can be deduced from their choice to ignore the experts and add LSD to the list? It seems they could have picked any number of other drugs with equal or greater justification; the more prevalent, less notorious drug psilocybin (magic mushrooms), or the even more popular and legal drug salvia. As the Expert Panel’s leader Dr Wolff notes, neither LSD nor psilocybin have ever been detected in anyone apprehended in the UK for drug driving, nor in any driver involved in a smash. The Expert Panel sagely noted that tripping on mushrooms or LSD “is not likely to be compatible with the skills required for driving”, (perhaps after consulting with Jon Snow), and recommended that forensic evidence from drivers and crashes be monitored so that evidence-based LSD or psilocybin or indeed salvia limits might be proposed in future. 

But the Government doesn’t intend to wait to get tough on the LSD “menace” (yes that word was really used). Could it possibly be that the ‘message’ – a Government standing strong against the drug scourge – has priority over actual evidence of any serious preventable threat? Are LSD-addled drivers top of the list of traffic safety worries? I previously pointed out that vehement anti-cat posturing by the Government would be rather more proportionate than their drug policies. Apologies for revisiting a theme, but Road Minister Stephen Hammond should take note that when British drivers see airborne cats zoom past their windscreens, that’s less likely to be an LSD-induced hallucination than the result of the 40% of pet-owners who, with no legal requirement to do so, don’t restrain their pets in the car. Why not institute zero tolerance on that? Whilst battling the as-yet undetected scourge of drivers on LSD or mushrooms, Hammond seems blithely unconcerned that bloody cats are wreaking destruction on our roads in ways both obvious and terrifyingly discreet

To conclude on a serious note, there’s a danger that people imagine that “totemic toughness” on drugs is cost-free, a good way of demonstrating to ourselves that we care about the tragedies caused by intoxicated drivers. Don’t be fooled. Policymakers who block out inconvenient evidence to pursue “totemic toughness” are rarely vindictive, indeed many see themselves as holding the moral high ground against cold scientific rationalists. They could hardly be more wrong. The moral basis is clear for criminalising intoxicated drivers. Testing a driver’s blood against an evidence-based limit, as recommended by the experts, provides a fair and objective legal standard for punishing a reckless behaviour that the public largely agree to be wrong. However, with the zero tolerance approach, the blood test is being put to an alarming new purpose, and gains a whole new meaning. Rather than being merely a tool that helps implement our existing values (that driving when impaired is wrong), the test itself becomes the moral arbiter that identifies if drivers are criminals. We are surrendering our measure of right and wrong to a forensic test.